From: "Lam Sai Kit, Kenneth" <lamsk@medicine.med.um.edu.my>

To: "'promed@usa.healthnet.org'" <promed@usa.healthnet.org>

Subject: Enterovirus 71 encephalitis Date: Thu, 28 Aug 1997 14:40:53 +0800

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During the on-going outbreak of hand-foot-mouth disease (HFMD) caused by enterovirus 71 in Malaysia, the University Hospital has seen two fatal cases of acute viral encephalomyelitis confirmed to be due to this virus.

Case 1: CS, a 3 year old Indian boy, had been well prior to his illness. He presented with a 3-day history of moderate fever and occasional cough. There was no history of any skin rash. On the night before admission, he appeared restless during sleep and awoke in the morning more lethargic than usual but still conscious and orientated. He vomited out some altered blood and was brought to the hospital. He was poorly responsive, cyanosed, tachycardic, tachypnoeic and in shock. He needed endotracheal intubation and assisted ventilation soon after arrival to hospital. There were bilateral crepitations on auscultation of the lungs. The heart was not enlarged. Despite maximal ventilatory and inotropic support the patient remained in decompensated cardiopulmonary failure and expired six hours after admission.

Case 2: MFI, a 3 year 8 month old Malay boy, was brought to the University Hospital in cardiorespiratory arrest. There was a history of 3-day high grade fever and was noted to be dyspnoeic by his parents a few hours earlier. He also had decreased oral intake due to painful mouth ulcers. On admission, he was unresponsive and in marked respiratory distress. He was tachycardic with a weak feeble pulse. There was no cardiomegaly and auscultation revealed normal S1 and S2 with no added sounds/murmurs. There was widespread crepitations of the lungs with a palpable liver of 3 cm. His chest x-ray showed patchy consolidation of all four zones with underlying fluffy alveolar infiltrates consistent with pulmonary oedema but the heart was not enlarged. He was intubated and given maximal ventilatory support but he developed a cardiac arrest and despite cardiopulmonary resuscitation, he died two hours later.

Laboratory investigation

Post mortem was conducted on both cases and the pathology findings showed predominant lesions of the brain stem and mild inflammation of the overlying meninges. The inflammatory response is predominantly mononuclear, suggesting an acute viral aetiology as a cause of the encephalitis. There was minimal damage to the cardiac tissues and all the other organs were unremarkable. The overall picture on autopsy was consistent with brain stem viral encephalitis.

Enterovirus 71 was isolated from the brain of Case 1 and from the spinal cord, brain stem, pericardium and stool of Case 2. Both the deceased had younger brothers who were admitted for observation and the sibling of Case 2 actually presented with HFMD. EV 71 was also isolated from the stool samples of both brothers.

Although the incidence of HFMD in the country has decreased, nevertheless it is important to put out an alert of this rare but fatal complication of EV 71 infection.

Prof. S.K. Lam Department of Medical Microbiology Faculty of Medicine University of Malaya 50603 Kuala Lumpur Malaysia.

Tel: 03-7502324

Fax: 603-7582801

E-mail: lamsk@medicine.med.um.edu.my

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